The hidden epidemiology of trauma in Nunavik: a call for a dedicated trauma registry

Abstract

Background:

Delivering trauma care in Nunavik is challenging. Despite the benefits of trauma registries, no routine data collection captures data from Nunavik patients in Quebec’s provincial database. We sought to compare trauma epidemiology from data collected on site in Nunavik with data from a governmental registry at a tertiary centre, hypothesizing sufficient cohort differences to justify a dedicated registry.

Methods:

We conducted a retrospective review of 2 cohorts (2015 to 2019). The first cohort included patients at Kuujjuaq’s Centre de santé Tulattavik de l’Ungava or Puvirnituq’s Centre de santé Inuulitisivik (the Nunavik cohort) and the second cohort included patients admitted to the provincial referral centre for the Nunavimmiut at the Montreal General Hospital (MGH). Nunavik data were collected through chart review, while MGH data were obtained from the McGill University Health Centre Trauma Registry. We analyzed patient demographics, injury mechanisms, transfer characteristics, and modifiable risk factors using descriptive statistics.

Results:

We identified 776 patients in the Nunavik cohort, of whom 42.0% were transferred to the MGH. Of all 776 trauma patients in Nunavik, only 14.3% were captured in the trauma registry. Among those transferred to the MGH, 33.9% were recorded in the registry, highlighting a gap in data representation. Patients in the Nunavik cohort were significantly younger (30 yr v. 37 yr, p < 0.001) and more often female (51.0% v. 38.8%, p < 0.001). Mechanisms of injury and vital signs also differed significantly (p < 0.001).

Conclusion:

Data from many patients from Nunavik are not captured in the governmental database, with the trauma epidemiology in the region significantly differing from those presenting to the tertiary centre. A dedicated prospective, sustainable registry is needed to improve quality of care and outcomes in Nunavik.

Delivering trauma care to the Inuit population of Nunavik presents unique challenges. Nunavik’s vast and sparsely populated geography, frequent weather-related travel disruptions, and fragmented transport infrastructure all pose substantial challenges in delivering optimal care.¹ Encompassing a large land area, the region is home to 14 000 residents, constituting 0.15% of Quebec’s overall population. Of these, 90% are Inuit, residing in 14 villages situated along the coasts of Ungava Bay, Hudson Bay, and the Hudson Strait.² The Nunavimmiut exhibit a strong sense of cultural identity, with the majority speaking Inuktitut, and represent a young and growing population.³ The Nunavik residents experience significant health disparities — including elevated mortality and hospitalization rates, as well as a greater loss of potential years of life because of both intentional and unintentional trauma — in comparison to the general Quebec population.^4–6 These health disparities stem from historical, economic, and governance inequalities that have oppressed and continue to affect this community. Examples include assimilationist education, child welfare policies, and systemic marginalization within colonial politics, all of which affect Indigenous people’s access to mainstream health care.⁷

Monitoring and evaluating care for trauma patients using valid quality indicators is crucial for identifying areas for improvement, ultimately leading to better outcomes such as reduced hospital mortality and enhanced recovery.⁸ The American College of Surgeons Committee on Trauma (ACS COT) mandates trauma registries, playing a vital role in this process. These registries, established worldwide in recent decades, provide a systematic method for collecting, analyzing, and disseminating data related to traumatic injuries, ensuring consistency and reliability while facilitating research and quality improvement initiatives.⁹ Compliance with ACS COT requirements reflects a commitment to maintaining the highest standards of trauma care.¹⁰ In Quebec, the provincial trauma registry (Système d’information du registre des traumatismes du Québec [SIRTQ]) routinely collects data from 60 designated trauma centres across the province.¹¹ However, there are no designated trauma centres in Nunavik and, as a result, trauma epidemiology in the region remains poorly defined. Currently, an injured patient from the region is included in the provincial database only if they are successfully transferred and admitted to the Montreal General Hospital (MGH), where the trauma registry — per SIRTQ inclusion criteria — includes only those admitted following a trauma event or who die in the emergency department, inherently excluding all patients who are assessed and discharged from the emergency department without admission. Unlike other nontrauma-designated hospitals in Quebec, Nunavik faces distinct and systemic challenges owing to its remote geography, limited trauma resources, and reliance on aeromedical evacuations, leading to delays in care. Despite a disproportionately high burden of trauma, data from this region are not systematically collected within the provincial framework. A dedicated trauma registry is essential to accurately capture epidemiology, support quality improvement, and guide resource allocation tailored to Nunavik’s needs.

In our study, we aimed to contrast Nunavik’s epidemiology of trauma captured by primary onsite data collection in Nunavik — as a surrogate for a local trauma registry — with that captured by traditional methods relying on a standard governmental registry at a tertiary level-1 trauma centre. We hypothesized that significant differences would be evident in the cohort characteristics, emphasizing the necessity for a dedicated trauma registry in the region.

Methods

Study setting

In Nunavik, 2 regional hospitals — the Centre de santé Tulattavik de l’Ungava (CSTU) in Kuujjuaq and the Centre de santé Inuulitisivik (CSI) in Puvirnituq — provide primary and limited secondary care to the resident population.¹ Each of the other 12 villages (6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast) have their own local community service centres.² Trauma patients from the surrounding villages are usually transferred by medical evacuation to the CSTU or CSI for assessment by on-call medical staff. The CSTU and CSI each has a general practitioner available around the clock for phone consultations with peripheral village clinics and to facilitate transfers as needed.^12,13 If tertiary trauma care is necessary, coordination occurs between the on-call physician and the trauma team leader at the MGH, the level-1 trauma referral centre in Montréal, with patient transfers achieved by fixed-wing air travel accompanied by health care personnel.¹⁴ Patients requiring higher-level care must therefore navigate the logistic complexities of air travel and cover more than 1600 km to reach Montréal.¹⁴ Of note, the MGH is the only trauma referral centre for all adult patients originating from Nunavik and therefore receives all patients requiring a higher level of trauma care from this region.

Study design

The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting criteria (Appendix 1, Table 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.013324/tab-related-content).¹⁵ The study was also approved by the director of professional services of Nunavik (N.B.). Community input and approval were obtained from Inuit leadership (L.W.) before submission for publication.

Table 1.

Patient characteristics

Variable	No. (%) of patients*		p value†
	Nunavik cohort n = 776	MGH cohort n = 366
Age, yr, median (IQR)	26 (18–42)	33 (23–48)	< 0.0001
Missing	3	0
Sex, male	380 (49.0)	224 (61.2)	0.0001
Initial systolic blood pressure, mm Hg, median (IQR)	120 (110–126)	122 (109–136)	0.0006
Missing	4	17
Initial heart rate, BPM, median (IQR)	82 (70–98)	91 (79–106)	< 0.0001
Missing	11	17
Initial GCS score, median (IQR)	15 (15–15)	15 (13–15)	< 0.0001
Missing	16	126
Initial oxygen saturation, %, median (IQR)	98 (96–99)	98 (96–99)	0.4
Missing	18	25
Supplemental oxygen required	68 (8.8)	53 (20.5)	0.0000
Missing	0	107
Cause of trauma			0.0005‡
Blunt assault	257 (33.1)	77 (21.0)
MVC	254 (32.7)	127 (34.7)
Fall	139 (17.9)	77 (21.0)
Other	88 (11.3)	20 (5.5)
Stabbing	32 (4.1)	53 (14.5)
Gunshot	6 (0.8)	12 (3.3)
Deceased	18 (1.5)	6 (1.6)	1

BPM = beats per minute; GCS = Glasgow Coma Scale; IQR = interquartile range; MGH = Montreal General Hospital; MVC = motor vehicle collision.

^*Unless indicated otherwise.

^†Categorical variables compared using χ² test unless otherwise specified. Continuous variables were non-normally distributed and were compared using a Wilcoxon rank-sum test.

^‡Fisher exact test used, given the small sample size.

We conducted a retrospective review of all data from adult trauma patients from Nunavik between Jan. 1, 2015, and Dec. 31, 2019. These dates were chosen to build on previous on-site data collection procedures completed up to 2014.¹ We identified 2 cohorts by conducting on-site chart reviews of trauma patients who presented directly to CSTU and CSI (the Nunavik cohort) and by conducting a query of the MGH trauma registry (the MGH cohort).

Data collection

For the Nunavik cohort, archivists at the CSTU and at the CSI identified all trauma patients according to prespecified International Classification of Diseases 10th Edition (ICD-10) codes related to traumatic injuries (codes V00–Y99). We included patients with injuries typically considered for trauma care, including fractures, head injuries, penetrating trauma, and high-energy blunt force mechanisms. We excluded patients who presented with nontraumatic conditions (e.g., medical emergencies, chronic orthopedic conditions). All patients presenting directly to these institutions or transported to the CSTU or CSI by medical evacuation from a peripheral village were included. Any patients who bypassed these hospitals were not captured in the data set and were therefore excluded.

We performed paper-based chart reviews to collect information on age, sex, clinical parameters (e.g., initial blood pressure, heart rate, Glasgow Coma Scale [GCS] score, oxygen saturation, and oxygen requirements on presentation), and injury mechanism characteristics. The category of motor vehicle collisions (MVCs) in our study included those involving cars, trucks, snowmobiles, and all-terrain vehicles, which aligns with trauma registry classifications and reflects the transportation modes commonly used in Nunavik. The collection of further diagnoses and outcomes was limited by the lack of availability of advanced imaging and more definitive interventions in the region.² Only a subset of these patients were transferred to the MGH for further specialized care.

To assess case overlap with the MGH cohort, we cross-referenced patients using their unique provincial identification number. However, inconsistent documentation and missing identifiers in the Nunavik charts posed challenges in directly linking cases across data sets. For the purposes of this study, the Nunavik cohort served as a surrogate for a potential regional trauma registry, capturing data from all trauma patients who presented for care in the region.

The MGH cohort was derived from the McGill University Health Centre (MUHC) trauma registry, which serves as the data source for the provincial trauma registry (SIRTQ). At the MGH, the trauma registry includes only patients who are admitted after a trauma event or those who die in the emergency department, per SIRTQ inclusion criteria. This inherently excludes trauma patients who are assessed and discharged from the emergency department without admission. Furthermore, data from trauma patients originating from Nunavik who do not require transfer to the MGH for definitive care, or who do not survive the transfer process, are not captured. To build this cohort, we included all patients in the MUHC trauma registry with home addresses located in Nunavik. To have a comparable cohort, we gathered variables from the registry identical to those obtained in the Nunavik registry and therefore excluded variables related to imaging findings and surgical outcomes.

Statistical analysis

We compared characteristics from the Nunavik and MGH cohorts with descriptive statistics. Given that continuous data were not normally distributed, we reported medians and interquartile ranges and compared cohorts using the Wilcoxon rank-sum test. We compared categorical data using the χ² test when counts for individual categories exceeded 10. Otherwise, we used Fisher exact tests. A p value less than 0.05 was considered statistically significant. We performed statistical analyses using R statistical software, version 3.5.3 (R Project for Statistical Computing).

Ethics approval

The study received institutional review board approval from the MUHC (no. 2021–7555).

Results

Figure 1 illustrates the overlap of trauma cases between the Nunavik cohort and the MGH cohort. The Nunavik cohort comprised 776 trauma patients who presented to the CSTU and the CSI during the study period, while the MGH cohort consisted of 366 patients. Of the 366 trauma patients identified in the MGH cohort, only 111 overlapped with the Nunavik cohort, leaving 255 patients unaccounted for in the local data set (Figure 1). Within the Nunavik cohort, 327 patients were noted to have been transferred to the MGH for further treatment; however, only 111 of these transferred patients were captured by the MUHC trauma registry.

Fig. 1.

Trauma patients included in the Nunavik and Montreal General Hospital (MGH) cohorts (2015 to 2019).

Univariate analyses are presented in Table 1. Patients from the Nunavik cohort were significantly younger (median 30 [IQR 15 to 46] yr v. 37 [IQR 24 to 51] yr; p < 0.0001,) and had a higher proportion of female patients (51.0% female), whereas males were more prevalent in the MGH cohort (38.8% female) (p = 0.0001). Within the Nunavik cohort, 32.4% were pediatric patients (aged < 18 yr), 59.8% were adults aged 18 to 64 years, and 7.8% were 65 years or older. The Nunavik cohort more often had a normal GCS score (median 15 [IQR 15 to 15] v. 15 [IQR 13 to 15]; p < 0.0001). There were statistically significant differences in initial heart rate (median 82 [IQR 70 to 98] beats per min in Nunavik cohort v. 91 [IQR 78 to 106] beats per min in MGH cohort; p < 0.0001) and systolic blood pressure (median 120 [IQR 110 to 126] mm Hg in Nunavik cohort v. 122 [IQR 109 to 136] mm Hg in MGH cohort; p = 0.0006).

There were also statistically significant differences in the mechanism of injury between the Nunavik and MGH cohorts (p = 0.0005). In the Nunavik cohort, blunt assault was the most prevalent cause of trauma (33.1%) followed by MVCs (32.7%) and falls (17.9%). In the MGH cohort, MVCs took precedence (34.7%), followed by blunt assault (21.0%), and falls (21.0%) (p < 0.0001). The MGH cohort exhibited a higher rate of penetrating mechanisms (stabbing 14.5%, gunshot 3.3%) than the Nunavik cohort (stabbing 4.1%, gunshot 0.8%). Upon analysis of MVC traumas, as outlined in Table 2, the MGH cohort exhibited nearly twice the incidence of pedestrian traumas at 17%, in contrast to 9% in the Nunavik cohort (p < 0.0001). To further characterize differences across the cohorts, we subdivided patients into 4 groups according to whether they were present in both cohorts (n = 111), present in the MGH cohort only (n = 255), present in the Nunavik cohort and transferred to MGH but not present in the MGH cohort (n = 216), or present in the Nunavik cohort only and not transferred to MGH (n = 449). Patients in the MGH cohort, whether present in both data sets or only in the MGH registry, tended to present with lower GCS scores and lower oxygen saturation, suggestive of greater injury severity (Table 3). In contrast, patients captured in the Nunavik cohort only— particularly those not transferred to MGH — exhibited more normal physiologic parameters on presentation.

Table 2.

Characteristics of motor vehicle collisions in Nunavik

Role	No. (%) of patients		p value
	Nunavik cohort n = 254	MGH cohort n = 127
Driver	168 (66.1)	68 (53.5)	< 0.0001
Passenger	46 (18.1)	22 (17.3)
Pedestrian	24 (9.4)	21 (16.5)
Cyclist	2 (0.8)	0 (0.0)
Other	0 (0.0)	1 (0.8)
Not specified	14 (5.5)	15 (11.8)

MGH = Montreal General Hospital.

Table 3.

Baseline characteristics of trauma patients in cohort subgroups

Characteristic	No. (%) of patients*
	Included in both MGH and Nunavik cohorts n = 111	Included in MGH cohort only n = 255	Included in Nunavik cohort and transferred to MGH but not in MGH cohort n = 216	Included in Nunavik cohort only, not transferred n = 449
Age, yr, median (IQR)	35 (25–51)	34 (24–49)	31 (23–44)	36 (25–53)
Sex, male	45 (40.5)	179 (70.2)	145 (67.1)	229 (51.0)
Initial systolic blood pressure, mm Hg, median (IQR)	121 (110–129)	131 (120–140)	120 (111–127)	140 (128–152)
Initial heart rate, BPM, median (IQR)	82 (71–98)	97 (83–110)	82 (72–99)	99 (84–114)
Initial GCS score, median (IQR)	15 (3–15)	12 (3–14)	15 (14–15)	12 (10–14)
Initial oxygen saturation, %, median (IQR)	97 (96–99)	93 (91–96)	98 (96–99)	95 (92–97)
Cause of trauma
MVC	33 (29.7)	70 (27.4)	51 (23.6)	129 (28.7)
Fall	29 (26.1)	69 (27.0)	58 (26.8)	105 (23.3)
Blunt assault	33 (29.7)	72 (28.2)	65 (30.1)	99 (22.0)
Stabbing	8 (5.4)	19 (7.5)	11 (5.1)	57 (12.7)
Other	8 (5.4)	25 (9.8)	22 (10.2)	59 (13.1)

BPM = beats per minuts; GCS = Glasgow Coma Scale; IQR = interquartile range; MGH = Montreal General Hospital; MVC = motor vehicle collision.

Discussion

In this retrospective cohort study, which relied on 2 distinct data collection procedures, we demonstrated significant differences between a surrogate for a Nunavik trauma registry and the current provincial database, suggesting that current data collection procedures portray an epidemiological picture of trauma in Nunavik that is incomplete and inaccurate. Of note, of all the injured patients who presented during the study period, only 14.3% would have been captured using the province’s standard data collection procedures. This highlights the importance of implementing a dedicated trauma registry in Nunavik to identify accurate and representative epidemiological statistics, monitor quality of care, and, ultimately improve patient outcomes.¹⁶

This study highlights the limitations of relying on a database at a tertiary care centre that requires a patient to have been transferred to and hospitalized at the centre for their data to be captured. This inherently introduces bias into data analysis, as this cohort is skewed toward patients with more severe traumas, as seen in differences such as lower GCS scores and increased oxygen requirements. Although some differences in vital signs, (e.g., heart rate, systolic blood pressure) reached statistical significance, vital signs remained within a physiologically expected range and the differences were unlikely to be clinically meaningful. We similarly observed that patients included in the MGH registry — either alone or also captured in the Nunavik cohort — tended to present with lower GCS scores and oxygen saturation levels, consistent with greater injury severity. The MGH cohort also included a higher proportion of pedestrians struck by MVCs, perhaps highlighting a population experiencing more critical injuries. This selection bias overlooks the broader epidemiology of incidents leading to hospital visits, potentially misguiding intervention strategies.¹⁷ In other words, a reliance on the current governmental trauma registry tends to overrepresent more severe traumas and overlook groups like females and those who have experienced blunt assault, who may be underrepresented in tertiary care data. This has important implications for resource allocation and injury prevention interventions. Our subgroup analysis further supported the hypothesis of a selective transfer pattern, with the MGH-only cohort showing the lowest GCS scores and highest prevalence of male patients, consistent with more severe trauma. In contrast, patients who were not transferred or not captured in the MGH cohort often had higher GCS scores.

Furthermore, our study demonstrated poor overlap between cohorts, raising concerns that trauma patients from Nunavik are not adequately captured in governmental databases. One key reason for this discrepancy is that the MUHC trauma registry includes only patients who were admitted to the hospital following their trauma or those who die in the emergency department. Many patients who were transferred from Nunavik may have been evaluated and treated in the emergency department but discharged without hospital admission, thus never being recorded in the registry. Based on our experience, these likely represent patients who were transferred to the MGH for imaging and subsequently discharged from the emergency department without a hospital admission or intervention. Furthermore, limitations in data linkage, such as inconsistent use of patient identifiers between the Nunavik records and MUHC registry, may have contributed to the large proportion of transferred patients missing from the registry. For example, of all the trauma patients who presented to the CSTU and CSI during the study period, only 14.3% were captured in the MGH cohort. There are numerous potential explanations for this discrepancy, most notably that most patients did not require both a transfer and a hospital admission to the MGH. The fact that 69.7% of the patients in the MGH cohort could not be linked back to the Nunavik cohort could be partially explained by severely injured patients who bypassed the CSTU and CSI and were flown directly to the MGH. However, these were most likely a minority of patients, and this finding more likely highlights the limitations of retrospective data collection from paper charts, which limited our ability to follow the patient’s trajectory through the trauma care continuum and reliably identify their point of origin. For example, employing home addresses to identify patient origin or injury location can lead to information bias, as injury location is not routinely captured in SIRTQ and many Nunavimmiut stay in Montréal longer than anticipated, given the complexity of health care access in Nunavik — a detail often missed by official residency records.^18,19 As such, this patient population may end up presenting directly to the MGH for trauma care without a transfer. The fact that the MGH cohort had nearly twice the incidence of pedestrian traumas may corroborate this hypothesis, given the lack of access to their home vehicles while in Montréal and the significantly higher density of motor vehicles on the island. This underscores the potential discrepancies in estimating patient transfers from Nunavik and highlights the gaps in current data capture mechanisms.²⁰ Overall, the poor overlap between cohorts sheds light on the hidden epidemiology of trauma in the region, as well as the difficulties in following patients’ trajectories using the current data collection methods. Implementing a prospective trauma registry within the local communities is the logical next step.²¹

Trauma registries are vital for documenting care of admitted patients, although they require substantial resource investments.²² Consistent dissemination of registry data fosters connections with potential policy-makers and administrators.²³ The concept of organized trauma systems and dedicated trauma registries originated in the 1970s, alongside the development of trauma centres in the United States. Comprehensive, standardized data collection emerged later, with ACS COT leading the first large-scale, multicentre study in 1982.²⁴ Globally, most developed nations maintain national trauma registries, such as the US National Trauma Data Bank, Germany’s TraumaRegister DGU, and Australia and New Zealand’s National Trauma Registry Consortium.^25–27 Additionally, the American National Pediatric Trauma Registry, active from 1985 to 2003, collected data from 80 hospitals, with data underpinning more than 60 peer-reviewed publications, including guidelines and policy statements on trauma practice.²⁸ Despite challenges, even lower-resource settings have established regional registries that are used for monitoring patient outcomes, identifying improvement areas, and enhancing care quality.^29–31 These registries drive advancements in epidemiology, injury control, and resource allocation²⁴ and facilitate improved patient care, injury prevention, and documentation of socioeconomic impacts.⁹

Trauma registries are essential tools for improving trauma care outcomes, particularly in remote communities with limited access to health care resources.³² These registries are valuable for collecting, analyzing, and monitoring trauma-related data, as well as aiding in understanding injury patterns and clinical outcomes in both rural and urban settings.^27,33 Discrepancies in epidemiology between rural and urban areas have been well documented, with rural regions often showing higher rates of trauma and comorbidities.³⁴ Once trauma registry data are used to highlight these differences, resources can be efficiently and effectively allocated, injury prevention programs can be customized to address specific needs, and quality improvement initiatives can be implemented to enhance outcomes in both rural and urban populations.^35,36

In remote communities, information from trauma registries is particularly valuable for the development of targeted quality improvement initiatives, resource allocation, identification of prehospital care priorities, and monitoring of changes in trauma system performance over time.^23,37,38 These registries offer a systematic approach to data collection that can guide the development of trauma systems tailored to the unique requirements of remote areas.²³ By integrating trauma registry data into real-time patient care, health care providers in remote communities can make informed decisions that lead to improved patient outcomes.³⁹ Additionally, trauma registries support trauma research efforts by providing a robust statistical model for evaluations of trauma activity and research initiatives.⁴⁰

Despite ongoing efforts, our understanding of trauma outcomes in Nunavik remains incomplete, primarily because of the absence of a dedicated local trauma registry.⁴¹ The underrepresentation of remote communities in tertiary care centre registries, as observed in Nunavik, mirrors a widespread issue observed in various global contexts with other remote populations.^42–44 Compounding the problem, Nunavik’s reliance on physical charts poses challenges for data completeness compared with electronic medical records (EMRs), despite widespread EMR adoption elsewhere in Canada.⁴⁵ Overall, high-quality data collection for Indigenous Peoples, who are predominantly overrepresented in rural settings, is globally compromised because of systemic barriers in health care.^46,47

Critical elements for the successful implementation of a trauma registry include a defined population, trained personnel, reliable data collection, and robust analysis.⁴⁸ Creating a sustainable trauma registry, specifically in low-resource settings, involves several key steps. First, engaging local partners is crucial for gaining support and ensuring the registry meets local needs. Partnering with local academic hospitals and health authorities is key.^49,50 Simplifying data collection methods makes the process more manageable and efficient. Securing diverse funding sources helps ensure long-term viability.⁴⁹ Next, integrating the registry with existing health systems allows for smoother implementation and a greater impact. Using the data for continuous quality improvement identifies areas needing attention and drives better patient outcomes.²⁴ Moreover, the development of a trauma registry should be tailored to the local context to ensure its sustainability.⁴⁹ This includes adapting strategies for deployment and maintenance to the local environment. Furthermore, establishing a hospital-specific data dictionary can enhance the competence of registry staff in managing trauma data.⁵¹

To develop a comprehensive trauma registry in Nunavik, data collection must be extended beyond the 2 regional hospitals to include the 12 community service centres that serve as frontline points of care in each village. A sustainable Nunavik trauma registry should include a decentralized data entry system, whereby basic trauma-related metrics are systematically recorded by health care professionals at these centres. Furthermore, collaboration with the provincial trauma registry (SIRTQ) may allow for retrospective identification of patients who bypass CSTU or CSI and are transferred directly to MGH or other tertiary institutions. Together, these strategies would enhance the completeness and representativeness of the trauma registry and provide a more accurate epidemiological picture of injury in the region. Our subgroup analysis offers a valuable framework for future research aimed at better characterizing patient trajectories and understanding the continuum of trauma care across the region.

In Nunavik, we recommend the following for the successful implementation of a trauma registry: community engagement, support, and ownership of the registry; long-term commitment of governmental sources of funding; recruitment and retention of local data collectors; streamlined data collection procedures that are easily incorporated within clinical charts; and regular robust analyses with data presentations to all involved parties.

Limitations

This study has limitations inherent to its retrospective nature and its reliance on paper charts at the 2 regional referral centres in Nunavik. It is possible that we did not capture data for all trauma patients in our on-site chart review. Furthermore, we did not capture data from trauma patients who presented to peripheral villages without being transferred to the CSTU or CSI. In both cases, however, including these patients would only further increase the number of patients missing from the current governmental database. Although not the focus of this study, the lack of injury-specific and outcome data is another limitation, as a direct comparison would likely further highlight differences between the cohorts. However, our inability to obtain this data was a direct consequence of the absence of advanced imaging and emergent surgical care in Nunavik, as well as the difficulties in linking data on patients’ trajectories using the current registry, all deficiencies that merit further study to properly augment local resources. Finally, there was an obvious selection and survival bias within the MGH cohort that drove many of the observed differences from the Nunavik cohort. Nevertheless, this only adds to the need for a local trauma registry.

Conclusion

This study confirms that current data collection procedures portray an epidemiological picture of trauma in Nunavik that is incomplete and inaccurate. Data from a substantial number of trauma patients are not routinely captured or are underrepresented within government databases. This should serve as a call to action to implement a prospective and sustainable Nunavik registry that is streamlined and well ingrained within the community.